The Royal College of Midwives (RCM) have announced they are ending their decade long campaign promoting ‘normal’ birth. ABOUT TIME TOO!

The campaign no doubt grew out of good intentions, in particular encouraging a return to more natural births. But as time has gone on, it has meant an increasingly unrealistic form of antenatal education has taken hold and become the norm. Incredibly with a caesarean rate of around 25% it is not unusual to attend UK antenatal classes which dismiss caesarean birth in a matter of minutes and which fail to talk about the implications of a ‘cascade of interventions’ and how to rationally manage this.

The RCMs change of heart has unfortunately come far too late for the many women who have had ‘normal’ birth promoted at the expense of informed guidance and whose expectations have been mis-managed to the extent they have experienced significant negative reactions to their birth. And let’s be clear about what this can mean:

delayed bonding

breastfeeding difficulties and early cessation of breastfeeding

no further pregnancies (even opting to adopt)

prophylactic caesareans

etc.

While I do not dispute the lack of sufficient funding in recent years has led to the woeful situation maternity care finds itself in, (which no doubt contributes to the increase in medicalised births-for reasons of both expediency and cost-effectiveness), this is however the current reality (albeit unacceptable). Women need information at their fingertips relating to ALL modes of birth and ALL interventions if they are to stand any kind of chance of coping with and feeling in control of their birth.

For a long time now, those of us monitoring maternity care have taken issue with the use of the term ‘normal’ with its implication that anything other than a totally natural birth is therefore ‘abnormal’. Women hear a lot about vaginal birth and coping techniques and practically nothing about interventions and caesarean birth. This absence has left many women so poorly informed that expectations rarely match reality. No wonder then that the incidence of emotional trauma has been rising.

It is great that the rhetoric around birth will be removing reference to ‘normal’ birth. However, I take issue with the blame the RCM appear to be placing at the door of the women themselves. On the one hand saying they don’t want to “contribute to any sense that a woman has failed” but then adding “unfortunately that seems to be how some women feel.” They do not appear to acknowledge the role their campaign has played in encouraging midwives to emphasize one mode of birth over another to the extent that balanced information is almost impossible to come by in many UK classes, ostensibly setting women up to fail.

As the Guardian article points out “the campaign was criticized in an inquiry into the deaths of 16 babies and three mothers at Furness general hospital in Cumbria between 2004 and 2013.” and found that the campaign appeared to influence a group of midwives to such an extent as to contribute to “unsafe deliveries due to [the midwives’] desire to see the women give birth without medical interventions “at any cost”.”

At its most extreme the campaign appears to have contributed to the loss of life-though the RCM strongly deny this. But at the very least it is clear the campaign has actively encouraged women to write birth plans specifying little or no pain relief and to be distrustful of all interventions thereby failing to prepare them adequately for the current realities of birth in the UK.

This change in rhetoric is very welcome, but only time will tell whether those midwives who strongly emphasize natural birth will actually adapt to offer a more balanced, open-minded approach to education, birth planning and the support of birthing women.

I haven’t checked Amazon for a while to see the latest reviews. It was a lovely surprise to see several new ones, all which had such lovely, positive things to say.

Thank you readers, I am glad it is proving so useful to so many.

Here are some of the comments that have just made my day:

Franca: “I read this book from cover to cover – it is the first unbiased, non judgmental, evidence based book I have ever read on the subject. An absolute must-read for anyone who might end up with a caesarean e.g. basically everyone who is pregnant! Brilliant book.”

Mazi: “The book is written in a very non-judgemental way and its only agenda appears to be to inform and support women (and birth partners). I certainly felt much more knowledgeable after reading this book. I would definitely recommend `Caesarean Birth’ for all mums to be, especially as despite being an outcome for many women it is so often given only lip service at ante-natal classes. I particularly liked the chapter on recovery as it gives excellent, practical advice on what to expect afterwards and how to cope, even if your section wasn’t planned.“

Anonymous Amazon customer: “Fantastically informative guide to c sections, all you need to know to be prepared.

Jennifer: “Brilliant prep before I had my planned c section. Felt much calmer as having read this.“

Agnieszka: “You only need this one book if you are considering an elective C-section or you need one for medical reasons. Finally facts not old women’s tales about the procedure. Also no breast feeding ‘propaganda’ in this book which is a nice change from other publications.“

Helen: “This book was really helpful with my decision on whether to have a c-section second time round. Definitely worth reading before giving birth.“

The surprising results of a recent study suggests they don’t want to know.

The study looked at women with low risk pregnancies who were planning a vaginal birth the majority of whom did not want a caesarean delivery if there was no medical need.

When asked whether they had checked out the caesarean rate in the hospital they planned to give birth in, the majority had not

55% did not believe that their choice of hospital might affect their chances of having a caesarean

When asked whether a high caesarean rate would lead them to change hospital 75% said no, they would rather stay with practitioners they had developed relationship with

The truely surprising result suggested that when women were told that whether or not they had a caesarean could actually depend more upon administration issues and hospital policies than whether they actually needed one or not, they still preferred to stay with the hospital.

“If [women] see a hospital with a 50 percent C-section rate, they don’t see their own chances of having a C-section as being 50 percent. Our research suggests they see it as an abstraction.”

It is unfortunately the case, in the current cost cutting climate, that medical need is not the only factor influencing practitioner decisions about caesarean birth. Ironically while there appear to be women having unnecessary caesareans in some cases, there are also those who want to make an informed choice in favour of a planned caesarean who are being refused that option.

The NCT and WI commissioned a survey in 2013 to understand women’s perception of their birth and postnatal experiences. As a result of that survey they have launched a national campaign for 2017 targetting ‘red flag events’ called ‘Support Overdue’

Red flag events are instances where levels of staff support for women is so low it is considered dangerous. The survey found that half the women surveyed (nearly 3,000) had experienced a red flag event during their birth. E.g. no one-to-one care during established labour, waiting for more than an hour to be stitched following vaginal injuries.

“The aftercare was awful, I was alone and in a lot of pain” (a quote from the survey)

Another key finding highlighted adequacies in postnatal care. E.g. 1 in 5 women unable to see a midwife postnatally as frequently as they felt necessary and for some leading to a notable delay in the diagnosis of health problems for either Mum or baby.

In a climate of policies driven by cost cutting, the results from the survey are no great surprise. E.g.

79% of Trusts did not meet recommended staffing levels

88% of women had never met the midwife that attended them for their birth

Elizabeth Duff (Senior Policy Advisor at the NCT) commenting on Woman’s Hour (Jan 2017) stated that understaffing was a significant problem and despite increases in the number of students training to be midwives their research is finding that many trusts simply “do not have the money to employ the midwives that they know they need.”

Review staffing with a view to fulfilling the standard, set by the four medical and midwifery royal colleges, of a midwife-to-birth ratio of 1:28 per year;

Take action to ensure continuity of care: NICE postnatal guidelines are robust, but seem to be implemented inconsistently across different areas. One trust in London reported it offered women three postnatal visits as standard, a neighbouring trust offered women just one – yet both reported they were delivering in line with the guidance. Poor data and recording hampers proper analysis and means it is difficult to get a comprehensive picture of care standards and service provision.

Enable women to build and maintain a relationship with their midwife: many women give birth in locations chosen by them and known to providers months beforehand; facilitating a relationship between midwives and women in their care would help provide much valued continuity of care from the antenatal period into labour and postnatal care. NCT Press release Jan 17th 2017

What is incredible is the inability of decision makers to connect astronomical maternity litigation costs with the radical cost cutting experienced by the NHS. How many deaths and near misses (never mind the cases of PTSD) do there have to be before they ‘get it’.

Posted incsections commentary|Comments Off on NCT and WI survey women’s experiences of birth and postntal care

“Every year in England there are almost 700,000 live births. In 2012/13, the associated maternity care cost the NHS around £2.6 billion. Having a baby is the most common reason for a hospital admission, but maternity is a unique area of the NHS because the services support predominantly healthy women through a natural life event that does not always require doctor-led intervention.

While most of these births are successful, in 2014/15 the NHS Litigation Authority reported that maternity claims represented the highest value of clinical negligence claims and the fourth highest by volume. Obstetrics claims equated to approximately 41% of the £1.1bn paid by the NHS Litigation Authority last year.” 2015 Survey of women’s experiences of matenity care, statistical release – Care Quality Commision (NHS)

What we should be asking is-what is going wrong with the care that there is such high levels of litigation every year. All too often the media blame those women requesting caesareans in the absence of medical need for rising costs and stretching resources. (Remember NICE themselves found that the cost of a vaginal birth that requires an anaesthetist (epidural or spinal pain relief) and any additional intervention e.g. episiotomy, tear repairs, prolonged hospital stay (2 nights or more) etc. bumps the cost to almost exactly the same as a planned caesarean with no medical emergency. Blaming these women and labelling them too posh to push is ignoring the elephant in the room – not enough midwives.

This destructive habit can cause significant problems between couples. Both feel that their daily life is the most difficult and that the other just doesn’t understand. It is easy to then let resentment fester under the surface and spend valuable time and energy arguing about who has the worse deal.

This behaviour can occur regardless of the type of birth you have had. Remembering that your birth partner has also gone through huge upheaval and stress is important.

They are sleep deprived, they are anxious, they witnessed their loved one in pain. They may have felt inadequate during the birth blaming themselves for not having prevented unwanted intervention. Then and once back at home they may be taking roles and making decisions on your behalf that they are not used to.

For example, unless discussed in advance your partner will, in the case of a general anaesthetic, be making decisions about feeding and clothing your baby for her first few hours. Unless you have discussed it in advance they are unlikely to know what you are planning to do and may not know the potential impact of giving formula instead of breast milk immediately after birth. Try not to criticise decisions, particularly if you did not discuss such eventualities beforehand – they will have done what they thought was right at the time.

Similarly, while you are recovering, some jobs you have previously done within the home probably now fall to them. Some may relish this, but others may feel the pressure, particularly if you are overly critical. This will all be in addition to their working day so quite quickly they are going to end up as exhausted as you. Appreciate what they are doing and try not to criticise when things are not done your way. Does it matter if the washing is left in the machine for 24 hours before going into the dryer? Probably not. Nor is it the end of the world if they gave the kids the wrong drinks in their lunchbox.

Ask each other for help and support and try to remember that you are both going through a huge learning curve while extremely sleep deprived.

It is only in truly believing the roles are totally different and have extreme and unique pressures of their own that you can hope to remove this barrier to emotional recovery.

A UK hospital has challenged targets handed down by others (in this case their Clinical Commissioning Group – those who set the targets for the hospital). The Royal Berkshire Hospital was told their caesarean rate was too high (27.1%) and they must get it down to 23%. When asked whether it was cost driving this target the interim Medical Director Brian Reid said “That would be the driver.”

Unfortunately this target led approach to hospital care of pregnant women is typcial rather than unusual. Targets are a major factor driving policy and practise in many places. Where targets are based on cost cutting this can only mean that the health and safety of pregnant women and their unborn child cannot take top priority.

women wanting to request a caesarean where there is no medical need should engage in a detailed discussion with their practitioners. All the risks and benefits of both vaginal and caesarean birth should be fully discuss but if, after this, the woman still prefers a caesarean this should be granted

women wanting to request a caesarean on the grounds of fear should be offered perinatal mental health support and if, following this, they continue to want a caesarean, this should be granted

So if more women are making an informed decision in favour of a caesarean birth over an attempted vaginal birth then the targets need to reflect this need.

The World Health Organisation retracted their recommended target 4 years ago when the studies on which they had based their recommendations were found to be flawed. They have now stated:

Despite this, official bodies continue to use such figures to beat their hospitals into submission with unachievable targets.

And lets be clear many caesarean requests are from women whose circumstances are not clear cut, where a decision in favour of either birth mode is equally justifiable. So simply telling them no when they ask for a caesarean and the press labelling these women as selfish or too posh to push is simplistic and insulting.

Take for example a baby lying in the breech position. A breech birth can be delivered vaginally or by caesarean section. However any woman making an informed decision about her birth will know that a breech position can make for a more protracted birth. Protracted births can increase the need for pain relief and instrumental assistance or ultimately an emergency caesarean. Couple with this, the fact that in the recent past many breech births have been delivered by caesarean, so practitioners are getting less experience with these births and this may justifiably lead some women to choose a planned caesarean over a vaginal attempt. These women are not selfish, they are making informed decisions on behalf of their own bodies and their baby’s.

So if you are planning your birth, read the NICE guideline and arm yourself with the facts prior to requesting a caearean, particularly one where there is no clear medical need. In addition my book “Caesarean Birth: A positive approach to preparation and recovery” provides all sorts of information about both caesarean and vaginal birth so that you can make an informed decision about which way you would prefer to proceed.

At long last there is a trial of the pioneering proceedure commonly referred to as a ‘Natural Caesarean’. Jenny Smith a senior midwife at Queen Charlotte’s and Chelsea Hospital in London developed the idea 10 years ago. There are many annecdotal benefits to the procedure and women report a much better experience of caesarean birth if they have been able to give birth this way. It is hoped that a successful trial will lead to this process being rolled out across the NHS.

We discussed this wonderful technique a while ago and there is an excellent video describing the process.

“It is about the mother. After the incision is made, the curtain is removed and the mother is able to see her little baby wriggle out. It is a special moment that is missed otherwise…The baby remains in the abdomen for up to four minutes and the mother can look at it, see its little face and eyes, and when it wriggles out it is the parents that first determine the sex.” Jenny Smith

The Royal College of Obstetricians and Gynaecologists (RCOG) have published a report into the ‘State of the Nation’ with regards Maternity Care. It makes for an interesting if somewhat alarming read. It seems that childbirth is falling fowl of the ‘Postcode Lottery’ that is affecting so many aspects of British life.

The report is very careful to point out that while the data quality of many of the hospitals require significant improvement, they have attempted to provide a status nonetheless.

“Some of the observed differences could be due to differences in the quality of the data submitted by trusts…over 10% of hospital trusts failed all data quality checks and [we call] for greater NHS trust engagement in ensuring that IT systems are fit for purpose.”

During our work on the 2011 NICE Guideline on Caesarean Section, csections.org and other organisations made a case for accurate reporting on births. In particular on the importance of separating out emergency from planned caesareans and the underlying indicators leading to each birth.

Media coverage of the recent report suggests that too many women are having planned caesareans prior to 39 week gestation-even in the absence of medical need. Once again the damning ‘Too posh to push’ label rears its head. However this may not be an accurate reflection of the report, for the reasons highlighted above and until such reporting is reliably undertaken by ALL hospitals in the UK it is not possible to say with confidence what the real situation is.

NICE Guidelinesare clear-delivery prior to 39 weeks should be avoided unless there is a clear medical reason for it. A baby’s lungs are less well developed prior to this time and are therefore at increased risk of complications.

WHAT DOES THIS REPORT REALLY TELL US?

That while we would like to trust our practitioners have our best interests at heart (and that of our baby), the presence of a ‘postcode lottery’ reveals that advice given to women may be biased by a combination of hospital policy and personal opinion. The hard truth is COST is a major factor in the type and level of care you might receive.